Original Article Efficacy of volar locking plate fixation for unstable distal radius fractures in elderly patients

Full text

(1)

Original Article

Efficacy of volar locking plate fixation for

unstable distal radius fractures in elderly patients

Minghui Wang, Bin Wang, Xiuhui Wang

Department of Orthopedics, Shanghai Pudong New District Zhoupu Hospital, Shanghai, China

Received September 20, 2016; Accepted January 8, 2017; Epub February 15, 2018; Published February 28, 2018

Abstract: Objective: This study was to investigate the efficacy of volar locking plate fixation for treating unstable

distal radius fractures (DRFs) in elderly patients. Methods: Thirty one patients (78.6 ± 3.6 years, range 75-91

years) with unstable DRFs were studied. Patients received volar locking plate fixation and postoperative functional

exercises. Results: Average operative time was 47.84 ± 8.68 min, and the average content of blood loss was 62.10 ± 11.67 mL. During the follow up of 4-12 months, excellent, good, middle and poor outcomes were obtained in 17, 11, 2 and 1 cases, respectively; that is to say, the good rate was 90%. Fracture healing appeared at postoperative

6.23 ± 0.62 weeks. There were radial palmar angle of 9.42 ± 3.02, ulnar deviation angle of 21.77 ± 0.88, radial shortening of 0.19 ± 0.65 mm and ulnar variance of -0.52 ± 0.47 mm. Conclusions: Volar locking plate fixation was

effective to treat unstable DRFs in elderly patients.

Keywords: Distal radius fractures, volar locking plate, elderly patient, preoperative preparations, postoperative

functional exercises

Introduction

Distal radius fracture (DRF) is one of the most common fractures of the upper extremity [1], as it accounts for 15% of all fractures [2]. Majority of DRFs are stable and treated with closed reduction and cast immobilization [3], whereas some DRFs are considered to be unstable [3] and require additional fixation [4]. In addition, closed reduction with cast immobilization is also not a good choice for elderly patients as it is prone to postoperative displacement and not well function recovery [5].

Many studies have documented that interlock-ing fixation is associated with good patient sat-isfaction, wrist function and restoration of phy- siological radius length [6-8]. Recently, volar locking plate is widely accepted as an efficient treatment for unstable DRFs due to the advan-tages of direct reduction, solid fixation as well as early mobilization of wrist fractures [9]. With the rising incidence of DRFs in an ageing population [10], the efficacy of volar locking plate for treating unstable DRF in elderly pati- ents is not well known. Especially as the elderly

osteoporosis, the anesthesia risk is high and it may be difficult to obtain good outcome via volar locking plate. A prospective randomized trial by Arora et al. found that older patients treated by volar locking plate fixation for dis-placed and unstable distal radial fractures had better grip strength than those by nonopera- tive treatment. Additionally, some other previ-ous studies also found that there were many satisfactory results of the volar locking plate in elderly patients with unstable DRFs [11-15]. However, the patients in these studies were in a large range of age (49-78 years or 17-79 years) or their age were not very old (above 65 years). Therefore, this retrospective study was aimed to investigate the efficacy of the locking plate fixation via volar approach for the treatment of unstable DRFs in elderly population (75 years old and older).

Materials and methods

Patient

(2)

unstable DRFs who were treated by locking plate fixation via volar approach between February 2010 and February 2014. The inclu-sion criteria were: (1) a clinical diagnosis of unstable distal radius fractures according to the clinical features summarized by Cooney [16], including the pulverized cortex at the dor-sal (volar) side of distal radius and displace-ment of articular surface greater than 2 mm; palmar angle tilting to the dorsal side > 20; radial shortening > 5 mm; anterior-posterior displacement more than 1 cm; and instability after fracture reduction and fracture prone to re-displacement. (2) an age of > 75 years; (3) patients who were able to take care of them-selves before the injury. The indication for this surgery including types A3, B1, B3, C1 and C2 fractures on the basis of Association for Osteosynthesis/Association for the Study of Internal Fixation (AO/ASIF) [17], patients who were tolerant of anesthesia and surgery. Pati- ent with unwillingness to taken the surgery, or with poor cardiopulmonary function, or who had senile dementia and can’t actively cooper-ate with physiatrician for the postoperative functional exercises were all excluded. The demographic data consisting of age and gen-der and clinical data including AO/ASIF type, radiological measurements, waiting time before

tive preparations, including cardiopulmonary function assessment via cardiac ultrasonogra-phy, anesthesia risk evaluation by anesthetist, phlebothrombosis prophylaxis with low mole- cular heparin, routine CT scan as well as 3D reconstruction examines were all performed for the assessment of displacement fracture. Besides, as for patients associated with frac-ture of femurs haft who also had severe anemia (hemoglobin < 5 g/dL [18]), red cells transfu-sion was given to correct anemia and surgery was conducted as early as their general state of health was stable.

Operative procedure

After brachial (plexus) block anesthesia or gen-eral anesthesia, the patient was in supine posi-tion with the injured forearm extended on a small table beside the operating table. Pneu- matic tourniquet was used to tie the upper arm. A volar incision was made starting at the shaft of radius, followed by a dissection to enter interspace between the flexor carpi radia-lis (FCR) muscle tendon and arteria radiaradia-lis, and ended at distal wrist flexion crease, with pronator quadratus and broken ends of frac-tured bone exposed. Following partial excision of pronator quadratus, the fracture was reduced

Table 1. The demographic and clinical data of pa-tients with unstable distal radius fractures (DRFs)

Parameter Patients

Mean age (range), years 78.65 ± 3.64 (75-91) Gender

Male, n (%) 2 (6.5%)

Female, n (%) 29 (93.5%)

AO/ASIF classification, n (%)

A3 15 (48.4%)

B3 6 (19.3%)

C1 8 (25.8%)

C2 2 (6.5%)

Waiting time before surgery, h

≤ 24 h 24 (77.4%)

24-48 h 7 (22.6%)

Associated injury or comorbidities, n

Fracture of femurs haft 5 Proximal humeral fractures 2 Hypertension or diabetes mellitus 22

Chronic bronchitis 12

Chronic atrial fibrillation 4

surgery and associated injury are shown in

Table 1. Briefly, all fractures were closed fractures due to a fall on the outstretched wrist. The fractures were classified as: 15 cases of A3, 6 cases of B3, 8 cases of C1 and 2 cases of C2. Preoperative X-radio- logical measurements showed that palmar angle tilted from -30° to 5° with a mean angle of -3.77 ± 7.15°; ulnar deviation an- gled from 0° to 15° with an average of 8.87 ± 4.24°; and radial shortening ranged from 2 to 10 mm with an average of 6.61 ± 2.25 mm; and ulnar variance ranged from 0 to 10 mm with an average of 2.81 ± 1.80 mm. This study was approved by the ethical committee of Shanghai Pudong New District Zhoupu Hospital.

Preoperative preparations

(3)

preopera-and held temporarily with thin Kirschner wire. A volar locking plate with appropriate length was placed on to the volar radius, with distal plate 2-3 mm below the articular surface, and sliding hole was temporarily fixed. Then, at least 4 locking screws (all screws of 2.4 mm diameter; the radial one of 16 mm length, the middle two of 20 mm length and the ulnaris one of 18 mm length) were used for distal fracture fixation after the plate position confirmed radiographi-cally and satisfactory reduction, and 3 screws (a cortical bone screw of 2.7 mm diameter and 16 mm length; the other two locking screws of 2.4 mm diameter and 14 mm length) were placed for proximal fracture fixation according to fracture condition. Finally after well fracture reduction and fixation were confirmed again, Kirschner wire was pulled out, following by suture. Five cases with fracture of femurs haft were also treated with closed reduction and PFNA internal fixation. Two cases with proximal humeral fractures were treated with open reduction and intramedullary nailing. A typical patient treated with volar locking plate fixation is shown in Figure 1.

Post-operation management

Antibiotics were used in 5 patients associated with fracture of femurs haft for infection pre-vention within 24 h, but not for others. Sy- mptomatic treatments of pain and anti-osteo-porotic medicine (Alfacalcidol, 0.5 μg/d) were given for all patients. During the oral adminis-tration of Alfacalcidol, 24-h collection of plas-ma and urine was conducted every three months for the detection of Calcium level. If hypercalcemia or hypercalcinuria occurred, Alfacalcidol would be forbidden until the blood calcium recovered to the normal. Then Alfa- calcidol would be given at the half of the last dose. External fixation was not necessary. Early functional exercise was performed under the guidance of a physiatrician: first flexion and extension exercises of fingers, then flexion and extension exercise of wrist joint 2 weeks later, and finally weight-holding heavy exercise delayed to 8-10 weeks later (according to frac-ture healing by radioscopy), as well as gradual strength function training.

Figure 1. The surgical procedure on a female patient (76 years old) with type C1 unstable distal radius fractures. A:

The volar locking plate was placed below pronator quadratus. B: Plate implant was finished. C: Locking screws were used for fracture fixation; well preserving pronator quadratus was (shown at the vascular clamps).

Table 2. Dienst wrist rating system

Grade Excellent Good Moderate Poor

Subjective evaluation

Wrist pain Absent Now and then Usually Continuing

Function Unlimited Limited when taking

aggravating activities Slightly limited at work Reduced working capability and limited physical labor Objective evaluation

Locomotor activity Normal Nearly normal Reduced Obviously reduced

Grip power Normal Nearly normal Reduced Obviously reduced

(4)

Follow-up

The intraoperative data consisting of operative time and blood loss were recorded, and pos- toperative data including palmar tilt, radial shortening, ulnar deviation and variance, frac-ture healing time and complications were all performed at follow-up. The wrist function was assessed under the Dienst wrist rating system [19] (Table 2), including the evaluation of ac- tive range of motion (ROM, palmar flexion and dorsal extension), wrist pain, and grip power measurement using a hydraulic dynamomet- er (Jamar, Clifton, New Jersey). Postoperative complications were recorded.

Statistical analysis

Statistical analysis was performed using SPSS 19.0 (SPSS Inc., Chicago, IL, USA). All results were reported as means ± standard deviation (M ± SD). The t-test was used to compare the preoperative and postoperative radiological measurements. P < 0.05 was considered as the statistical significance.

Results

The average operative time of the patients was 47.84 ± 8.68 min, with a range of 30-70 min (Table 3). The average blood loss content of the patients during surgery was 62.10 ± 11.67 mL, with a range of 40-90 mL. All patients were fol-lowed up for 4-12 months (average 7 months). According to Dienst wrist rating system, 17 patients obtained excellent outcome, 11 cases with good outcome, and 2 cases with moderate and 1 case with poor outcome, hence, the good rate was 90%.

Postoperative X-radiological examinations sho- wed that fracture healing appeared at postop-erative 6.23 ± 0.62 weeks in all patients, with a range of 6-8 weeks (Table 3). After surgery, the average of radial palmar angled increased significantly compared with preoperative mea-surements (9.42 ± 3.02° vs. -3.77 ± 7.15°, P < 0.01) (Table 4); the average of ulnar deviation angled increased significantly in postopera- tive measurements (21.77 ± 0.88° vs. 8.87 ± 4.24°, P < 0.001) (Table 4); the average of radi-al shortening reduced significantly (0.19 ± 0.65 mm vs. 6.61 ± 2.25 mm, P < 0.001) (Table 4), and the average of ulnar variance reduced sig-nificantly in postoperative X-radiological mea-surements (-0.52 ± 0.47 mm vs. 2.81 ± 1.80 mm, P < 0.01) (Table 4). No patients experi-enced loosening of the internal fixation, infec-tion, or complications such as nerve and ten-don injury (as a case shown in Figure 2). No reduction loss and aggravating displacement occurred after the surgery.

Among the three patients with middle or poor outcome, one case with plate at a distance of 5 mm from the articular surface had the reduc-tion loss of articular surface at the follow-up of 1 month, as well as decreased wrist ROM, grip power and sometimes pain. The symptom was alleviated after the plate was removed one year later. In the other case with the screws entered into the distal radioulnar joint, the rota-tion funcrota-tion was also limited. The limited func-tion was improved after removing internal fixa-tion six months later. In the third case with plate partial to radialis, the flexion function of thumb was limited during the follow up.

Discussion

Generally, closed reduction and cast immobili-zation treatments were selected for elderly

Table 3. Intraoperative and postoperative data of patients with unstable distal radius fractures (DRFs)

Mean (range) Operation time, min 47.84 ± 8.68 (30-70) Blood loss, mL 62.10 ± 11.67 (40-90)

Fracture healing (range), weeks 6.23 ± 0.62 (6-8) Active range of motion

Palmar flexion 49.35 ± 5.82 (35-60) Dorsal expansion 31.68 ± 3.76 (25-40) Wrist pain

0 14 (45.2)

1 4 (12.9%)

2 9 (29.0%)

3 1 (3.2%)

5 1 (3.2%)

Locomotor activity

Normal 14 (45.2%)

Nearly normal 15 (48.4%)

Reduced 2 (6.5%)

Grip power

Normal 1 (3.2%)

Nearly normal 28 (90.3%)

(5)

especially for advanced aged DRF patients. However, as to the patients with unstable DRF and who were also associated with osteoporo-sis, plasters were not good choice of treatment to maintain fractures reduction and make for bone healing [5]. With the improvement of anesthesia and orthopedic fixation techniques, especially the appearance of lock plate, the stability of osteoporotic fractures was improved greatly, and volar DRF surgical techniques were also increasingly practiced in elderly patients [20]. In this study, we investigated the efficacy of the locking plate fixation via volar approach for the treatment of unstable DRFs in elderly population (75 years old and above). The re- sults showed that most patients obtained good reduction and function recovery during the follow-up period, and no patients experienced loosening of the internal fixation, infection, or complications such as nerve and tendon injury, consistent with previous study by Orbay and Fernandez who reported that a volar fixed-angle plate provided stable internal fixation, good final results and minimized the complica-tion rate in the elderly populacomplica-tion [11]. However, a comparative study of clinical and radiologic

outcomes reported that nonoperative ment might be the preferred method of treat-ment in elderly population, in spite of better radiographic results (dorsal tilt, radial inclina-tion, and radial shortening) in patients treated by volar fixed-angle plate fixation than those by cast immobilization [21], because unsatisfac-tory radiographic outcome in older patients did not necessarily translate into unsatisfactory functional outcome. Considering the shorter following-up in our study, a further prospective study with a long follow-up time was needed. As most of elderly unstable DRF patients were usually associated with hypertension, diabe-tes, chronic bronchitis and other internal dis-eases, preoperative assessments of operative and anesthesia risks were necessary. Except for preoperative preparations, some details of operative procedure should be also noted: 1) For elderly unstable DRF patients with osteopo-rosis, especially female patients, Kirschner wire will be needed for temporary fixation after the completion of the reduction; the plate should be placed 2-3 mm under the articular surface. If it was too low below the articular sur-face, fixation would not be solid, as evidenced

Table 4. Preoperative and postoperative radiological measurements

Parameter Radiological measurements P value

Preoperative Postoperative

Palmar tilt angle -3.77 ± 7.15 (-30-5) 9.42 ± 3.02 (0-12) P < 0.01 Ulnar deviation angle 8.87 ± 4.24 (0-15) 21.77 ± 0.88 (18-23) P < 0.001 Radial shortening, mm 6.61 ± 2.25 (2-10) 0.19 ± 0.65 (0-3) P < 0.001 Ulnar variance, mm 2.81 ± 1.80 (0-10) -0.52 ± 0.47 (-1-0) P < 0.01

The t-test was used to compare the preoperative and postoperative radiological measurements. P < 0.05 was considered as the statistical significance.

Figure 2. The radiological measurements of a female patient (75 years old) with type C2 unstable distal radius fractures: preoperative anteroposterior (A) and lateral (B) X-radiographs; postoperative anteroposterior (C) and

lat-eral (D) X-radiographs showed that fractures and joint surface were anatomical reduction, and the internal fixation

(6)

by one case of postoperative re-displacement occurred in this study. 2) A good exposure is needed to avoid repeated fluoroscopic exami-nation and prolonged operative time. The pro-nator muscle should be protected during the operation. Dos Remedios et al. [22] pointed out pronator muscle played an important role in the wrist function, including forearm rotation and distal ulnar joint stability. Above all, minimally invasive was advocated to avoid pronator mus-cle damage. 3) As to patients with type C2 frac-tures, especially who had crushing volar corti-cal bone, loss of the distal radius would occur even though Kirschner wire fixation was per-formed after reduction. Thus, it would be better to fix distal end of fracture firstly, then loosen oval foramen of the plate and draw again, and finally tight the screws after distal radius restor-ing to normal height. 4) Palmar approach might be associated with tendon rupture or other complications. Tarallo et al. [23] conducted a retrospective study to investigate the complica-tion incidence s of volar locking plate fixacomplica-tion for unstable DRFs. The result showed that 18 of 303 (5.9%) DRFs patients suffered from complications after volar locking plate fixation and extensor tendon injury accounted for 50% of all complications due to technical defect of the internal fixation. In our study, we also found that the complications of volar locking plate fixation of DRFs were related to technic- al defects during internal fixation. Fortunately, this complication could be avoided by careful operative procedure. 5) For unstable DRFs, distal radioulnar join dislocation should be noticed and corrected timely. In our study, one patient obtained not well rotation function dur-ing follow-up because his dislocation was not observed in time. 6) The protection for soft tis-sue should be considered during the surgery because of the poor flexibility of the skin and soft tissues were relatively poor in elderly patients; the affected limbs should be elevated postoperatively to lessen edema.

Conclusion

Several limitations in our study must be ad- dressed. The number of the cases included in the study and follow-up period were insuffi-cient. Comparison between non-operative tre- atment and volar locking plate fixation was not performed. Thus, further prospective studies with large population and long follow-up time were required to evaluate the clinical outcom-

es of DRFs in elderly patients by volar locking plate fixation. Not with standing its limitation, this study did suggest that volar locking plate fixation combined with preoperative prepara-tion may be a good choice for treating uns- table DFRs in elderly patients, who were able to take care of themselves before the injury. It should provide a therapeutical reference for DRFs elderly patients, especially in the graying of society.

Acknowledgements

This study was carried out in Shanghai Pudong New District Zhoupu Hospital. This study was supported by the training of academic leader of Pudong New Area health system (Contract No: PWRd2014-15).

Disclosure of conflict of interest

None.

Address correspondence to: Xiuhui Wang, Depart- ment of Orthopedics, Shanghai Pudong New District Zhoupu Hospital, Shanghai 20131, China. Tel: +86-21-68135590; Fax: +86-+86-21-68135590; E-mail: 13361845169@163.com

References

[1] Bohra AK, Vijayvergiya S, Malav R and Jhanwar P. A prospective comparative study of opera-tive treatment of distal radius fracture by using

locking and non-locking volar T-plate. Journal

of Pharmaceutical and Biomedical Sciences© (JPBMS) 2012; 20.

[2] Barrie KA and Wolfe SW. Internal fixation

for intraarticular distal radius fractures. Tech Hand Up Extrem Surg 2002; 6: 10-20.

[3] Fernandez D WS. Distal radius fractures. In: Green DP, Hotchkiss RN, Pederson WC, wolfe

SW, editors. Green’s Operative Hand Surgery, Elsevier; 2005. pp. 645-710.

[4] Ayong S, Traore A, Postlethwaite D and Barbier O. Functional evaluation of unstable distal ra-dius fractures treated with an angle-stable vo-lar T-plate. Acta Orthop Belg 2014; 80: 183-189.

[5] Tsukazaki T, Takagi K and Iwasaki K. Poor cor -relation between functional results and

radio-graphic findings in Colles’ fracture. J Hand

Surg Br 1993; 18: 588-591.

(7)

[7] Lattmann T, Meier C, Dietrich M, Forberger J

and Platz A. Results of volar locking plate os -teosynthesis for distal radial fractures. J Trau-ma 2011; 70: 1510-1518.

[8] Konstantinidis L, Helwig P, Strohm PC,

Hirsch-müller A, Kron P and Südkamp NP. Clinical and

radiological outcomes after stabilisation of complex intra-articular fractures of the distal radius with the volar 2.4 mm LCP. Arch Orthop Trauma Surg 2010; 130: 751-757.

[9] Johnson N, Cutler L, Dias J, Ullah A, Wildin C

and Bhowal B. Complications after volar lock

-ing plate fixation of distal radius fractures. In -jury 2014; 45: 528-533.

[10] McKay SD, MacDermid JC, Roth JH and Rich-ards RS. Assessment of complications of distal radius fractures and development of a

compli-cation checklist. J Hand Surg Am 2001; 26:

916-922.

[11] Orbay JL and Fernandez DL. Volar fixed-angle plate fixation for unstable distal radius frac -tures in the elderly patient. J Hand Surg Am 2004; 29: 96-102.

[12] Arora R, Lutz M, Fritz D, Zimmermann R,

Ober-ladstätter J and Gabl M. Palmar locking plate

for treatment of unstable dorsal dislocated dis-tal radius fractures. Arch Orthop Trauma Surg 2005; 125: 399-404.

[13] Arora R, Lutz M, Deml C, Krappinger D, Haug L and Gabl M. A prospective randomized trial comparing nonoperative treatment with volar

locking plate fixation for displaced and unsta

-ble distal radial fractures in patients sixty-five

years of age and older. J Bone Joint Surg Am 2011; 93: 2146-2153.

[14] Arora R, Lutz M, Hennerbichler A, Krappinger D, Espen D and Gabl M. Complications

follow-ing internal fixation of unstable distal radius fracture with a palmar locking-plate. J Orthop

Trauma 2007; 21: 316-322.

[15] Kim JK and Rhee SJ. The results of unstable

distal radius fracture following volar locking plate fixation in elderly patients. Journal of the

Korean Orthopaedic Association 2011; 46: 387-391.

[16] Cooney WP. Fractures of the distal radius.

A modern treatment-based classification. Or -thop Clin North Am 1993; 24: 211-216. [17] Kreder HJ, Hanel DP, Mckee M, Jupiter J, Mc

-Gillivary G and Swiontkowski MF. Consistency of AO fracture classification for the distal radi -us. J Bone Joint Surg Br 1996; 78: 726-731. [18] Dzik WH. Innocent lives lost and saved: the im

-portance of blood transfusion for children in sub-saharan africa. BMC Med 2015; 13: 22. [19] Dienst M, Wozasek GE and Seligson D. Dynam

-ic external fixation for distal radius fractures.

Clin Orthop Relat Res 1997; 160-171. [20] Matschke S, Marent-Huber M, Audigé L, Went

-zensen A; LCP Study Group. The surgical treat-ment of unstable distal radius fractures by an-gle stable implants: a multicenter prospective study. J Orthop Trauma 2011; 25: 312-317. [21] Arora R, Gabl M, Gschwentner M, Deml C,

Krappinger D and Lutz M. A comparative study of clinical and radiologic outcomes of unstable colles type distal radius fractures in patients older than 70 years: nonoperative treatment

versus volar locking plating. J Orthop Trauma

2009; 23: 237-242.

[22] Dos Remedios C, Nebout J, Benlarbi H, Care-mier E, Sam-Wing JF and Beya R. Pronator qua-dratus preservation for distal radius fractures

with locking palmar plate osteosynthesis. Sur -gical technique. Chir Main 2009 28: 224-229. [23] Tarallo L, Mugnai R, Zambianchi F, Adani R and

Catani F. Volar plate fixation for the treatment

Figure

Table 1. The demographic and clinical data of pa-tients with unstable distal radius fractures (DRFs)

Table 1.

The demographic and clinical data of pa-tients with unstable distal radius fractures (DRFs) p.2
Figure 1. The surgical procedure on a female patient (76 years old) with type C1 unstable distal radius fractures

Figure 1.

The surgical procedure on a female patient (76 years old) with type C1 unstable distal radius fractures p.3
Table 2. Dienst wrist rating system

Table 2.

Dienst wrist rating system p.3
Table 3. Intraoperative and postoperative data of patients with unstable distal radius fractures (DRFs)

Table 3.

Intraoperative and postoperative data of patients with unstable distal radius fractures (DRFs) p.4
Table 4. Preoperative and postoperative radiological measurements

Table 4.

Preoperative and postoperative radiological measurements p.5
Figure 2. The radiological measurements of a female patient (75 years old) with type C2 unstable distal radius fractures: preoperative anteroposterior (A) and lateral (B) X-radiographs; postoperative anteroposterior (C) and lat-eral (D) X-radiographs showed that fractures and joint surface were anatomical reduction, and the internal fixation position was well.

Figure 2.

The radiological measurements of a female patient (75 years old) with type C2 unstable distal radius fractures: preoperative anteroposterior (A) and lateral (B) X-radiographs; postoperative anteroposterior (C) and lat-eral (D) X-radiographs showed that fractures and joint surface were anatomical reduction, and the internal fixation position was well. p.5

References

Updating...